Emicizumab Breakthrough Bleeding — RACP Adult Medicine MCQ

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HardHaematologyEmicizumab Breakthrough BleedingRACP Adult Medicine

A 40-year-old man with known haemophilia A (severe, <1% factor VIII) on emicizumab prophylaxis sustains a major trauma with intra-abdominal haemorrhage. What is the critical consideration when treating his acute bleeding?

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Correct answer: A — FEIBA (activated PCC) must NOT be given concurrently with emicizumab due to thrombotic risk

Emicizumab is a bispecific antibody that mimics factor VIII but does NOT provide complete haemostatic coverage for major bleeding. For breakthrough bleeding on emicizumab, bypassing agents may be needed. However, FEIBA (activated PCC) must be avoided or used with extreme caution (lowest effective dose) due to the risk of thrombotic microangiopathy and thromboembolic events when combined with emicizumab. Recombinant FVIIa (NovoSeven) is the preferred bypassing agent. For patients without inhibitors, recombinant FVIII can also be used.

Reference: National Blood Authority – 2024 – Haemophilia Management; AMH – 2025 – Emicizumab